during my army career i was an intensive care nurse for ten of those years. at eisenhower army medical center our physicians would write our order for vasopressors, insulin drips and heparin as titrate to a specific value depending on the drip and call me if …. that is how we managed therapeutics that are as we would say fluid. there was no need to write orders for changes, but our nursing documentation had to be very complete and precise.
in my world verbal orders are a serious concern. the expectation of cms is that verbal orders are accepted by licensed personnel (nurse, pharmacist). cms put this wording into 42 cfr 482.23©(2)(i) if verbal orders are used, they are to be used infrequently. this is in the cms world is recognized as a safety issue. cms’ approach is if a patient needs a lot of verbal orders maybe the physician needs to be present directing the care. it is interesting that cms put this regulatory line only in the nursing conditions of participation. this would lead one to think that nurses are, as the patient advocate, expected to tell the physician enough i am not taking another verbal order because i need you here. i realize the problems that may cause, been there done that.
lastly a verbal order must be spoken and the nurses in my hospital will only take telephone orders. if the physician is present they are handed to chart. and the requirement for the authentication of that order is actually written as promptly and failing that, within 48 hours. i have had reports from fellow compliance professionals that their facility was cited by cms when the verbal order was signed within 48 hours because the issue at hand was critical and the physician should have come in after giving the order to check on the patient. some may say that is unreasonable. i personally have sat with cms folks and they can be very insistent.
reference: state operations manual, appendix a survey protocols. regulations and interpretative guidelines for hospitals.
this is a lot and i hope you find it helpful. richard